Healthcare Provider Details

I. General information

NPI: 1447561741
Provider Name (Legal Business Name): INNOVATIVE SENIOR CARE HOME HEALTH OF EDMOND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 N MAY AVE STE 147
OKLAHOMA CITY OK
73112-3973
US

IV. Provider business mailing address

PO BOX 51266
LAFAYETTE LA
70505-1266
US

V. Phone/Fax

Practice location:
  • Phone: 405-341-4361
  • Fax: 405-341-4349
Mailing address:
  • Phone: 337-233-1307
  • Fax: 337-443-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA L. PROFFITT
Title or Position: PRESIDENT
Credential:
Phone: 337-233-1307